“Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events. NIOSH investigators identified the following items as key contributing factors in this incident that ultimately led to the fatalities:

Construction features of the house built into a steep sloping hillside

Natural and operational horizontal ventilation

Ineffective size-up

Fire fighters operating above the fire

Ineffective fire command communications and progress reporting

Lack of a personnel accountability system.”

The report is pretty detailed:

And here are some recommendations from the Feds:

“Recommendation #1: Fire departments should ensure that standard operating guidelines (SOGs) are developed and implemented for hillside structures.

During this incident, the E26 officer knew the fire was below him but he was unaware of just how many floors. If an adequate size-up had been conducted, or had the E26 officer obtained more intelligence information from the resident of the home that he spoke to briefly upon arrival, it may have facilitated a more rapid determination of the location of the fire floor.

Recommendation #2: Fire departments should ensure that an adequate size-up of the fire structure is conducted prior to crews making entry.

In this incident, if an effective size-up would have been conducted several factors may have changed the first arriving companies’ tactics. The B side door would have been an option for initial entry. If the small window below the front door would have been noticed perhaps the fire could have been seen on the basement floor; or if more intelligence information would have been gathered from the occupant initially they could have identified that the fire was on the basement floor and how to access the floor.

During this incident, E32 was originally assigned as RIC then re-assigned fire fighting duties to back up E11. E20 was dispatched as RIC but did not arrived on scene until after the victims were recovered.

Recommendation #4: Fire departments should ensure that a personnel accountability system is established early and utilized at all incidents.

In this incident, BC6 and the IC tried to radio E26 with no response and it was assumed they were with BC9 or that BC9 knew what they were doing. An additional supporting component to fireground accountability is frequent progress reporting. When the IC fails to get a response after 3 attempts, or he receives a garbled response, action must be taken to determine the crew’s status. A worst case scenario must be assumed until their status can be confirmed.

Recommendation #5: Fire departments should ensure that fireground operations are coordinated with consideration given to the effect horizontal ventilation has on the air flow, smoke, and heat flow through the structure.

At this incident, the officer on E26 realized that they had a fire somewhere in the structure, probably underneath them. The victims from E26 had deployed a 1¾” hoseline to the ground floor of the structure attempting to locate the fire. BC9 came into the structure and met them during their investigation of the ground floor. Victim #1 advised BC9 that the fire was underneath them. BC9 agreed to this and decided to take a crew down side B and attack the fire through the exterior doorway on side B at the basement level. BC9 and the IC discussed and agreed on this tactic. E26 did not receive any further instructions and did not leave the structure but attempted to go to the basement via the interior stairs. E26 did not provide any radio reports to the fire attack group supervisor (BC9) or the IC of their location or actions.

When an incident transitions from an investigation mode to an offensive fire attack mode, the IC should ensure that all companies have and understand their assignments, and are accounted for in the Personnel Accountability System. This information should be collected on a tactical worksheet to ensure that all companies have an assignment and are accounted for.

Recommendation #6: Fire departments should ensure that the Incident Commander is provided a chief’s aide at all structure fires.

In this incident, a chief’s aide may have helped the IC to establish and manage the tactical worksheet early in the incident, track the deployment location of the E26 crew, and monitor transmissions on the fireground channels.

Recommendation #7: Fire departments should ensure that an incident safety officer is assigned to all working structure fires.

In this incident, for the size of the fire department and responsible coverage area, there is an insufficient number of incident safety officers (ISO) and/or qualified personnel (certified to NFPA 1521) to act as an ISO within the fire department. The ISO should be of a rank worthy of the significant responsibility.”